Provider Demographics
NPI:1265129233
Name:WILLIS, SHAREE BROOKE
Entity type:Individual
Prefix:
First Name:SHAREE
Middle Name:BROOKE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25581 S HIGHWAY 48
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-3961
Mailing Address - Country:US
Mailing Address - Phone:918-509-0306
Mailing Address - Fax:
Practice Address - Street 1:25581 S HIGHWAY 48
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010-3961
Practice Address - Country:US
Practice Address - Phone:918-509-0306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator